Cardioversion

Debbie Sevant BHF Arrhythmia Nurse Specialist Essex Cardiothoracic Centre

Cardioversion
Safe and effective treatment to restore the heart to a normal rhythm Common treatment for Atrial Fibrillation Other rhythms may be cardioverted Treatment protocols vary

Case Study
A 45 year old lady with a history of diabetes presented to her GP with shortness of breath and fatigue. Examination revealed an irregular pulse. ECG revealed Fast Atrial Fibrillation, heart rate 140 bpm.

Why do I need Cardioversion ?

Normal Conduction AF - chaotic electrical activity Causes fibrillation of atria of the heart Loss of atrial kick / contraction Can cause Symptoms & Complications

Symptoms
Asymptomatic Mild to severe GP, clinic, urgent treatment SOB Fatigue Dizziness Syncope Chest pain

Complications of AF
Risk of blood clots 5 fold increased risk of stroke Aspirin Warfarin

Risk stratification CHAD, NICE

Initial Treatment of AF
Control Heart Rate < 80bpm at rest
Beta Blockers Calcium Antagonists Digoxin Emergency - Cardioversion

Initial Treatment of AF

Reduce risk of Blood Clots

Aspirin Warfarin

Who is suitable for Cardioversion?

Heart Rate Control

Patients over 65 Patients with coronary heart disease

Cardioversion
Presenting for the first time with lone AF Younger patients Patients with Symptoms Patients with AF secondary to another cause eg. Thyroid abnormality, post surgery

Patients unsuitable for cardioversion Patients who cant take antiarrhythmic drugs No Symptoms

History of Cardioversion
1775 Abildgaard
showed that hens could be made lifeless with electrical impulses and he could restore a pulse with electrical shocks across the chest.

First Cardioversion
1947 Claude Beck
pioneering cardiovascular surgeon in Cleveland, successfully defibrillates a human heart during cardiac surgery. The patient was a 14 year old boy His prototype defibrillator followed experiments on defibrillation in animals performed by Carl J. Wiggers,

Chemical Cardioversion
Cardioversion can be chemical or electrical Chemicals alter the hearts electrical properties to suppress the abnormal heart rhythms and restore a normal rhythm In- Patient Out-Patient Common Amiodarone, Sotalol, Flecainide

Direct Current Cardioversion

Electrical cardioversion - a synchronized electrical current (shock) is delivered through the chest wall to the heart through special electrodes or paddles that are applied to the skin of the chest and back Interrupt the abnormal electrical circuit(s) in the heart and to restore a normal heart beat

Procedure
Hospital Setting Day case Nurse, Anaesthetist, ODA, Cardiologist Warfarin levels prevent stroke TOE GA or Sedation Fast 6 hours Take all medication that day except diabetic

Paddle Position

Result

Synchronised Amount of Joules Success 99.4% locally biphasic technology

Recovery
Minor skin burn common Arrhythmia - bradycardia Clot Event 1 in 100 Anaesthetic Effect Do NOT drive 24 hours No important decisions 24 hours Accompanied home Pacemaker Check

How effective is it ?
50% recurrence within a year Increased risk of recurrence with repeat procedures Follow Up Often none NICE : 1 month & 6 months RAAF Experience Consider Ablation

Case Study
A 45 year old lady with a history of diabetes presented to her GP with shortness of breath and fatigue. Examination revealed an irregular pulse. ECG revealed Fast Atrial Fibrillation, heart rate 140 bpm. Atenolol 25mg od was commenced to reduce her heart rate.

Case Study
A referral was made to the local Rapid Access AF Clinic and Warfarin was commenced The Patient was seen in the Rapid Access AF Clinic 2 weeks after referral Echocardiogram at that clinic showed a normal heart Admission for DC Cardioversion was arranged once INR was within range Referral to Treatment 12 weeks

Case Study
This lady successfully cardioverted to normal rhythm with one 200 joule shock She was seen 3 months after DC cardioversion in the AF follow up clinic ECG showed normal rhythm and warfarin was stopped